ORIF – Calcaneal Fractures

Bruce J. Sangeorzan, MD and Stephen K. Benirschke, MD

The diagnosis and treatment of intra-articular fractures of the calcaneus have become more sophisticated over the past century, primarily over the past decade. However, appropriate treatment of calcaneal fractures remains controversial and often confusing to surgeons who lack extensive exposure to and experience with them. Despite new developments, twenty percent of patients presenting with an intra-articular fracture of the calcaneus are expected to develop some form of permanent functional disability, regardless of the treatment/management method.

Recent studies have pointed to the fact that patients, in whom anatomical reduction was achieved have better clinical scores than those patients treated nonoperatively. The dilemma remains, however, if patients show no improvement in pain and return to work with subtalar motion, why operate? Additional controversy exists relating to the mode of operative fixation of calcaneal fractures, including: timing of surgery; incision/approach; type of fixation (screws, bone-plates, staples, wires/pins); should a bone graft be used; postoperative casting versus early motion; and when to allow weight bearing. No consensus has yet been reached in the literature.

Volume V, No. 4 of the VJO featured an in-depth calcaneal fracture review and the operative technique employed by Tampa Bay trauma specialist Dr. Roy Sanders. For a continuation of the VJO's research into optimal calcaneal fracture management they traveled to Seattle, Washington, and the Harborview Medical Center to meet with doctors Bruce Sangeorzan and Stephen K. Benirschke who, since 1985, have been actively involved in the development and evolution of a surgical technique which is providing their calcaneal fracture patients with optimal results.

Their technique involves a unique exposure difference from those of Palmer and Lettournel. This more radical "J" approach is essentially a periosteal cutaneous flap that is a terminal extension of the peroneal artery. Because of the robust vascular nature of this flap, one is able to utilize this approach to restore lateral anatomy and overall height of the calcaneus without jeopardizing skin closure or vascularity. This approach has allowed an extension of operative timing to as much as four to six weeks. In addition, their technique employs a use of either "H" or "L" reconstruction bone-plates coupled with small one-quarter tubular plates for reconstruction of the lateral calcaneal wall.

References

Crosby LA, Kamins P The history of the calcaneal fracture Orthop Review 1991;20(6):501-509